School nurses face challenges meeting health needs of all students

Judy Camerlengo (above) is a school nurse for the Redwood City School District. Around 2 o’clock on May 19, 2017, her hands filled with supplies and her bag filled with paperwork, Camerlengo made her way to her car to head to her next school site. (Bethney Bonilla/Peninsula Press)

On a recent Friday, minutes before noon, Judy Camerlengo met a second grader for diabetic care in her office, a small room with a desk, cork board, cot bed and medicine cabinet at a Redwood City elementary school.

Camerlengo, a petite 68-year-old with reading glasses, shut her office door before checking the student’s blood sugar levels. “You can’t be distracted,” she said. “In a hospital setting a dosage of insulin is checked by two registered nurses, but in the school setting it’s just me.”

In the student’s lunchbox, Camerlengo found Post-it notes from the mother identifying the grams of carbohydrates in each food item. After a prick of the young student’s finger, Camerlengo used the carbohydrate count and blood glucose levels to calculate a dosage of insulin to administer before the student left for the cafeteria to eat with friends.

As Camerlengo’s office door remained closed for diabetic care, students filed in with stomachaches, itchy throats, a scraped knee and a lost tooth. Each had to be treated by the office secretary, who performed first aid while Camerlengo was busy. On other days Camerlengo deals with students with asthma, seizure disorders and food allergies.

Gone are the days of a nurse simply doing vision screenings and doling out Band-Aids in one school. In Redwood City and many other communities, more students with serious health conditions are getting care from school nurses, many of them racing from school to school.

Dr. Rayhan Lal, an internist and pediatrician specializing in endocrinology at Stanford, notes that the incidence of chronic diseases, including diabetes, is up, and advances in treatment have led to an increase of students needing medical care at school. (EDITOR’S NOTE: Peninsula Press is a project of the Stanford Journalism Program and not directly associated with Stanford Medicine.) That means more work for nurses like Camerlengo.

Yet the statewide number of students per nurse has grown. In 2010, California had 2,187 students per school nurse, according to the National Association of School Nurses. Only eight states had a higher number. By 2015, that number had risen to 2,784 to 1, with the ratios varying widely among districts, according to KidsData.org. Redwood City has 1,590 students per registered school nurse.

In May 2016, the American Academy of Pediatrics recommended that every school have a nurse on campus. As of April 2017, 22 states had statutes or administrative regulations requiring school nurses, and only 15 states required certain staffing ratios, but California is not one of them, according to research by The Network for Public Health Law.

“The state of school nursing has changed in the last 20 years that I have been a school nurse,” Camerlengo said. “When I first started we were at one school site the whole day. But now the medical needs of our students have changed and there’s more demand for direct care during school hours.”

Blood glucose testing, carbohydrate counting and insulin administration are common tasks for a majority of the registered nurses in Redwood City School District. Diabetic care, however, is but one of many medical conditions being managed by the nursing team, made up of five registered school nurses serving 7,951 students across 16 elementary and middle school campuses in Redwood City.

Camerlengo said when she first started there was one student with diabetes in the district. Now there are six.

Phoebe Reid-Chambers, a seven-year nurse in the district, said nurses shift school sites to cover students who need insulin or diastat, an emergency medication for seizure disorders. Most nurses visit three or four schools each week.

“In our district only licensed personnel are allowed to administer insulin and give diastat,” Reid-Chambers said. “Since I started we’ve seen an increase in both. I think we currently have about five diastat orders at different schools.”

Camerlengo said the increasing demand “does not allow the school nurse to offer more comprehensive care, thorough followups and more communication with teachers, administrators and staff. I’m sure many school nurses feel frustrated with not being able to give the kind of care they would like to.”

Indeed, Dr. Lal said doctors often rely on school nurses caring for their patients to give a more in-depth picture of what’s happening, in addition to preventative care.

“We have an old saying, an ounce of prevention is worth a pound of cure,” Dr. Lal said. “It’s definitely to the public benefit if school nurses can, in addition to managing chronic diseases, work on other health projects like vision screenings, hearing screenings, obesity screenings and early intervention. They’re on the front lines, so if we don’t have that help that certainly is a public health issue.”

The current state of school nursing

After a hectic lunch hour of health treatments and first aid, Camerlengo said many nurses eat lunch while driving to the next school. She estimated a nurse averages 30 students a day for first aid, in addition to providing diabetic care, dispensing routine prescriptions and asthma treatments, tending to allergic reactions, caring for students with epilepsy and other medical conditions, filing paperwork, following up with doctors, creating care plans and organizing screenings.

In the absence of tiny footsteps, she shared a story of receiving a call over a walkie-talkie to rush across campus to the school’s front office.

A second-grader had walked in with a stomachache and a funny feeling in his throat. The office manager called the student’s parents and was told to give him Benadryl. When the student started vomiting copiously she called Nurse Judy for help.

When Camerlengo arrived, she saw the ill child and told the office manager, “Call 911, I’m going to administer the EpiPen.”

“I remember thinking I was glad I was there that day,” Camerlengo said.

While an anaphylaxis reaction, a severe, potentially life-threatening allergic reaction, is rare, she said that with an increase in food allergies, her team is more commonly preparing for this type of emergency.

Licensed vocational nurses, who work under the supervision of registered nurses, cover school sites with seizures when a registered nurse isn’t there.

With an increase in students requiring one-on-one care and nurses rotating school sites daily, office staff and teachers in Redwood City, like many school districts today, are trained to handle first aid and other medical care when a nurse isn’t on site, including how to administer EpiPens and seizure protocol. Camerlengo said parents are called more frequently to pick up students as well.

But that worries some parents. Mary Hockaday, mother of two students at Roy Cloud Elementary, described the lack of a full-time nurse as “nerve wracking.”

“It is concerning not only for my 11-year-old daughter, who has a severe peanut allergy, but my younger daughter, who fell off the monkey bars the other day. She cracked open the back of her head but the nurse wasn’t there,” Hockaday said.

“I realize there is a staff shortage of nurses and I get that it’s hard for the district to pay for a nurse to be at every single school,” Hockaday said. “But it’s unfortunate the district can’t afford even a part-time nurse, every day. It’s sad that a school nurse is considered an extra thing.”

The nurses also oversee care for medically fragile students, some of whom may have more than one diagnosis. Valerie Cantrell, a nurse in the district, serves a majority of the medically fragile children.

Cantrell said she often relies on knowledge gained as a hospital nurse for nearly a decade to serve these students with conditions like epilepsy, cerebral palsy, glycogen storage disorder (which requires tube feedings) and vacterl association (which requires collecting waste from the body).

“For three months, I had two students at noon every day, one who has Type 1 diabetes and a student with a severe medical diagnosis that requires blood sugar checks and G-tube feedings,” Cantrell said. “It was crazy because there were also kids coming in with bloody noses and first aid needs, and the nurse is expected to care for all of the children at the same time, while students miss class as they wait.”

Many school districts began shedding funding for nurses during the 2008 recession, when they faced declines in state and local funding. Experts are concerned that with the continued increase in medical conditions, the workload on small nursing teams will undermine the ability to provide support to all children.

According to a study conducted in 2014 by the Division of Nursing at California State University, Sacramento, in collaboration with Lucile Packard Foundation, the situation is particularly severe in California, where school districts are not required to employ a school nurse and a lack of a mandated student-to-nurse ratio leaves 57 percent of public school districts reporting no nurse on staff.

“What startled us most was how many nurses reported doing advanced nursing procedures,” said Dr. Dian Baker, director of the study and the school nurse credential program at the university. “While this work is for a minority of the students this opens the door to another whole piece of the puzzle that no one is thinking of. We are doing reactive nursing rather than proactive care.”

Andrea Garen, director of health and wellness at the Redwood City School District, said covering the needs of students is a constant juggling act. “We’re constantly getting a new student with some medical condition and then training more staff,” she said. “The amount of time that goes into making the schedule, then adjusting that schedule, creates more work because nothing is stable.”

With management of severe illnesses taking priority, she said preventative care like immunizations and screenings often gets delegated to the licensed vocational nurses and retired registered nurses who volunteer.

“We’re overtaxing our nursing staff,” Garen said. “The awareness of what the nurses do, the level of care they’re providing to our students, hasn’t necessarily caught up with the reality of the large number of students who need their care. The traditional resources aren’t meeting the need.”

Funding falls short

While California schools are not mandated to hire school nurses, state and federal laws require districts to meet the medical needs of students with disabilities and other health conditions. “This situation leaves school districts a great amount of leeway in how they want to staff,” said Pamela Kahn, the incoming president of the California School Nurse Organization.

Kahn said this brings into question whether the standard of care provided is distributed evenly across school districts, which she believes it is not. In Orange County, where Kahn works, she said there are school districts that vary from a ratio of one nurse to 1,300 students to a district that has one nurse for about 15,000 students.

“Districts have a lot of choice depending upon their priorities and their school board’s priorities, as to how they want to staff their school health services and that creates a lot of disparity in practice and standards of practice,” Kahn said.

California’s state funding formula also plays a role, as property taxes impact a school district’s resources and per pupil spending. For example, in Palo Alto, where high property taxes allow the district to receive revenue beyond what they would collect from the state, a special nursing team is available to manage lunchtime diabetic care for students. Redwood City School District relies on state aid and diabetic care is added to the typical nurse’s workload.

Kahn said a majority of districts pay for nurses from their general funds, while others work to get Medi-Cal reimbursements or grants from community health care districts.

But even when funds are available, some districts struggle to recruit and retain credentialed nurses because of the high cost of living in the Bay Area. In Redwood City, the school nurse starting salary is $51,199.

“I would like to see a school nurse at every school. I’m sure many school nurses feel frustrated with not being able to give the kind of care they would like to give,” Judy Camerlengo (above) said at an elementary school in Redwood City, California. Photo taken on May 19, 2017. (Bethney Bonilla/ Peninsula Press).

Around 2 o’clock on a recent Friday, Camerlengo headed to meet a team of parents and teachers to consult on a new student with a seizure disorder.

“In this day and age, with the medically fragile and diabetic students, the number of school nurses is surprising to me,” she said. “I don’t know how schools without a nurse or even one nurse handle it.”

Baker said enrollment in the nurse credential program at Sacramento State has more than doubled in four years. With nurses available for hire, the shortage stems from a lack of funded nursing positions.

Earlier this year, California Assemblyman Joaquin Arambula (D-Fresno), pushed a bill that would have created a statewide task force to study school health issues and identify potential funding but it did not advance beyond the Appropriations Committee.

After 20 years of serving students in Redwood City, Camerlengo retired at the end of this school year. Redwood City has already started the search for her replacement.

Her hands filled with supplies and her bag filled with paperwork, Camerlengo made her way to her car to head to her next school. “If we were able to be in one place we would be able to do a lot more and get to know the students better,” she said. “But it’s rewarding to make a difference in the lives of children and for the medically fragile to make their experience as normal as possible. And I’m okay with that.”